Randa’s blood pressure had risen again, and I needed to know why.
An African-American police officer in her 40s and a single mother of three, Randa’s lips parted in a jovial smirk. “You really want to know?”
Randa had already had a rough year. After a protracted battle with painful, heavy menstrual periods, she decided to have a hysterectomy last winter, which went fine; but she had far more than the expected amount of nausea while recovering from surgery. Her obstetrician, Dr. B., ordered an abdominal ultrasound because, as he told me later, “One of my attendings during my residency told me to be curious.” He uncovered an unsuspected problem: a cancer (renal cell carcinoma, originating from one kidney cell gone awry) at the bottom of Randa’s left kidney.
Why didn’t he see this during the operation? Because the uterus, ovaries, intestines, liver, and other abdominal organs lie within the peritoneal cavity. The peritoneum surrounding this cavity is a smooth, sterile, glossy, gray sac that separates the abdominal and pelvic organs from the retroperitoneal space behind them, where one finds the kidneys. Dr. B. couldn’t see the kidneys during the hysterectomy.
He can take credit for saving Randa’s life. Diagnosing renal cell carcinoma is often challenging because it does not cause symptoms suggestive of kidney disease. It occurs in men twice as often as in women, and the age of peak incidence is 60. The only known risk factors for the disease are cigarette smoking and exposure to cadmium. Randa was not the right age or sex, nor was she exposed to either risk factor. All of which proves the tenet that patients do not always read our textbooks; in medicine, we sometimes meet our adversaries in the most unexpected places. We would not have found her cancer until much too late without her surgeon’s “curiosity.”
So, a couple of weeks later, Randa found herself on the operating table again and left it without her left kidney. Fortunately, the cancer had not spread into the fatty capsule surrounding the kidney nor into any of the nearby lymph nodes, so she had a decent chance at a cure and wouldn’t need chemotherapy or radiation.
Over the next couple of months, she did well, and her high blood pressure, which had required two medications to control over the previous three years, vanished. I was able to taper her off both medicines. But while I was doing this, it became obvious that the scar from her kidney operation was forming a painful keloid. Keloids are like nonmalignant cancers of scar tissue; they can grow big and ugly. Sometimes they hurt. They occur most often in black people.
“I can’t wear my police belt,” she complained.
“The weight of it causes too much pain.”
Her scar was now a pencil-thick hockey stick, with the blade pointing down and to the right from the lower margin of her mid-abdomen, just below the sternum, the long handle extending gradually downward from that same margin all the way across to the far left side. Its pink radiance was not the gentle pink of a rose petal but the angry pink of a first-degree burn. Its induration penetrated beneath its visible margins toward Randa’s subcutaneous fat, and the pressure of my hand upon it elicited from her a grimace that one might see on the face of a tough cop nursing a fresh knife wound.
As often happens in today’s managed-care environment, her pain became our pain. The plastic surgeons in her insurance plan did not want to see her, because the plan pays them a fixed amount (“capitation”) for each patient who joins the plan; it doesn’t pay extra to take care of an individual patient. Because a keloid often becomes a chronic problem requiring multiple office visits, many plastic surgeons try to avoid seeing patients with keloids who have a capitated insurance plan.
First, I sent her to see the best plastic surgeon in our region, Dr. K. He met with her a couple of times and once injected her scar with corticosteroids (cortisone analogs), which are strong anti-inflammatory agents and are the first-line treatment for keloids. When this did not help, she tried to get another appointment, but the doctor’s office put her off so many times, she gave up. The other plastic surgeon in the plan refused to see her.
Several months passed. In desperation, I called Dr. T., a personable plastic surgeon five miles away, and he gave us a chance. First, he explained to me the injection technique so that I could give her another trial of a corticosteroid injection. Then he asked me the key question: “Does she have any other keloids from her other surgeries or wounds?”
“Well, then, she should have her keloid excised surgically; she’s the ideal candidate.”
That month, Randa switched her provider plan from the local plan to the one in the next town so that I could refer her to Dr. T. The plan in the next town also pays capitation, but Dr. T. did not let that prevent him from performing the surgery she needed, and now her pain is almost gone.
Which is why I couldn’t understand this latest rise in her blood pressure. “Yes” was my reply; I really did want to know.
For months, a man had been bothering Willis, Randa’s youngest (midteen) son. The perpetrator often followed him home and threatened him. It progressed to where the man and his friends were throwing rocks through the windows of Randa’s house. “I had to file several police reports to make sure we had it all documented.”
One day, the conflict escalated. Her older son Eric came out of the house and found that this man was yelling at Willis and had him in a headlock. “Eric is kind of thin and not a strong guy,” she explained. He yelled at the man to let go of his brother, but the abuse continued. Angry and frightened, Eric returned to the front door. When he found that he was locked out of the house, he summoned enough powerful rage to break through the locked door. He went inside and found his mother’s gun.